• 
• 

Three Part Question

IN[adults with chronic musculoskeletal back pain] IS [acupuncture better than standard treatment] AT[improving pain relief]

Clinical Scenario

A 55 yr old man comes to A&E with persistant lower back pain. He has been suffering from back pain for the last 5 yrs for which he takes NSAIDS and goes for regular physiotherapy. His pain doesn seem to be getting better. On examination he has paraspinal muscle tenderness and no neurological deficit. Apart from offering him different oral analgesia and advising him to continue his physiotherapy, there is little else you can offer him. You have heard that accupunture offers some benefit in such cases and wonder what the evidence is to support this?

Search Strategy

Medline 1966-03/2005 using the OVID interface
Bandolier on line 04/05
Cochrane Issue 1, 2005
Medline
[{exp Acupuncture Therapy/ or Acupunture.mp. }AND{ Back pain.mp. or exp Back Pain/ or (pain adj back).mp. [mp=title, original title, abstract, name of substance word, subject heading word} limit 5 to (humans and english language)]
Bandolier
"Acupuncture" as key word
Cochrane
"Acupuncture" as key word

Search Outcome

189 papers were found on Medline, 1 abstract of a systematic review was found on Cochrane Database and 1 article on Bandolier online.
No additional papers were found on any of the other searches.
The table includes the sytematic review in 1999 which was further updated in 2004 as well as the article from Bandolier Individual papers are not included in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bandolier Feb 1999; 60-2	Extensive electronic search. Authors publising within previous five years were contacted.	Meta-analysis	Number of papers included	12 studies, out of which 4 were blinded. Not all papers had extractable outcome data	Difficulty in assessing acupuncture trials, whether the acupuncture has been done correctly. Small numbers
			Qualtity of studies assessment	Methodological quality ( randomization, blinding, withdrawals) and Quality of accupuncture; judged independently (and blind) by 6 experienced medical accupuncturists
			Adequacy of acupuncture was judged on 0-2 scale (max 2)	2 in one study, 1 in eight and 0 in three studies.
			In the 4 blinded trials	73/127 (57%) improved with acupuncture v/s 61/123 (50%) improved with control; relative benefit of 1.2 (95% CI 0.9-1.5) and the NNT to achieve short-term improvement was 13
			In the 5 non-blinded trials	78/117 (67%) improved with accupuncture v/s 33/87 (38%) improvement with control; relative benefit was significant at 1.8 (95% CI 1.3-2.4) and NNT was 3.5
van Tulder, Maurits W. PhD*; Cherkin, Daniel C. PhD†; Berman, Brian MD‡; Lao, Lixing PhD, LAc‡; Koes June 1999 Netherlands	Computer-aided search of the MEDLINE (1966–1996), EMBASE (1988–1996), and Cochrane Complementary Medicine Field databases using the search strategy recommended by the Editorial Board of the Cochrane Back Review Group	Systematic Review	Number of papers identified	52 artlices were identified and 11 were included	Only RCTs included Small numbers of patients in all trials 17-100
			Acupuncture v/s no treatment	3 studies
			Acupuncture v/s conventional treatment	2 studies. The study by Garvey et al was of higher methodologic quality and the study of Lehmann et al of lower methodologic quality. The overall conclusion of the reviewers concerning both was neutral, indicating that there was moderate evidence to show that acupuncture is not more effective than trigger point injection or transcutaneous electrical nerve stimulation (TENS).
			Acupuncture v/s placebo or sham acupuncture	8 studies. 2 high quality studies. Conclusion of the authors 'positive'; conclusion of the reviewers 'neutral'. In the Duplan B et al study seemed to have more severe complaints and in the Garvey et al study the acupuncture method was questionable. Of the remainng 6 low qaulity studies, the reviewrs conclusion of 5 was neutral and in 1 it was 'unclear'
Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM 20 September 2004 UK	Extensive electronic search. Updated search from 1996 to February 2003 following previous review	Systematic Review	Number of studies included	35 RCTs for chronic back pain	These effects were only observed immediately after the end of the sessions and at short-term follow-up. Most studies were of lower methodoligical quality Small numbers
			Pain relief and functional improvement	Better with acupuncture, compared to no treatment or sham therapy
			Authors view of balance of results	No conclusion on acute low-back pain.For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only

Clinical Bottom Line

Acupuncture may be of short term benefit in chronic low-back pain and may be a useful adjunct to conventional therapies.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Bandolier Acupuncture for back pain? Bandolier Feb 199; 60-2
2. van Tulder, Maurits W. PhD*; Cherkin, Daniel C. PhD†; Berman, Brian MD‡; Lao, Lixing PhD, LAc‡; Koes The Effectiveness of Acupuncture in the Management of Acute and Chronic Low Back Pain: A Systematic Review Within the Framework of the Cochrane Collaboration Back Review Group Spnie Volume 24(11) 1 June 1999 p 1113
3. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM Acupuncture and dry-needling for low back pain (Cochrane Review - abstract) The Cochrane Database of Systematic Reviews 2005, Issue 1 2005, Issue 1